Guidelines are in the Eye of the Beholder

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (ie, the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive. I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist. Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, “Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography.” Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I’d like. “No downsides”? Not for him, that’s for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.

The gynecologists are no better. They all still insist on annual visits for paps to find cancers that take 10 years to grow (and then only in the presence of HPV) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of “the best medical care in the world”.

What to do, though?

First, stop asking the foxes what they think of the new hen house alarm system. What do you think a urologist is going to say about PSAs? Why would a surgeon ever recommend against a mammogram? And whatever you do, don’t even think about questioning the need for an annual gynecological exam. Goodness. What’s a poor doctor to do without providing all that care? Starve?

Actually, you might be able to get an appointment with a urologist in less than six weeks for a kidney stone if they weren’t so booked up with annual rectal exams and PSAs on every asymptomatic man over 50. Think about getting in to see a gynecologist for heavy bleeding in less than 3 months. Not only would the care be more appropriate, but those same specialists worrying about their empty appointment books would probably be making more money by seeing patients who actually need their specialized skills and procedures.

So if you shouldn’t ask the specialists about screening guidelines, to whom should patients turn? How about me. Why not discuss these complex issues with your family doctor, who doesn’t make any money off your PSA or your pap or your mammogram. Believe me, my schedule is plenty full with sick people and the worried well (defined as those patients I cannot talk out of all those inappropriate interventions. Yes, they’re out there. Yes, I try to explain it to them. Am I always successful? Of course not, though it’s not for lack of trying.)

I’m more interested in seeing that the care you get is medically and scientifically appropriate, especially when deciding which screening interventions to forgo. “Watching and waiting” is often as viable a strategy for cancer as it is for lesser ailments. Let us family physicians educate you, our patients, so that you don’t end up with irreparable harm from treatments intended to cure something that would never have killed you. Sometimes “just getting it out of  my body” leaves you much worse off than leaving well enough alone.